The Acute Physician: Dealing with Death. Olivier Gaillemin Consultant Physician in Acute Medicine Salford Royal Foundation NHS Trust

Transcription

1 The Acute Physician: Dealing with Death Olivier Gaillemin Consultant Physician in Acute Medicine Salford Royal Foundation NHS Trust The Society for Acute Medicine, 6 th International Conference, October 2012

2 Deflection Evolving Role of Acute Medicine Ambulatory Care Hot clinics Virtual Wards Early Assessment / Treatment of Critically Ill Management of Level 2 Care Interface Beween ED and Specialty Wards Interface between Community and Hospital Early Safe Discharge Short Stay Units Rapid Review clinics

3 Evolving Role of Acute Medicine DEALING WITH DEATH Failure? Opportunity? Responsibility?

4 Preferred vs Actual Place of Death Preferred Actual 63% Own Home 29% Hospice 3% Hospital 1.5% Care Home 3.5% Other 21% Own Home 5% Hospice 53% Hospital 18% Care Home 2% Other

5 More numbers 78% of people will have 1 or more admissions in last year of life 89% who die in hospital had emergency admission 32% die within 3 days 12% admitted from a care home 9.4 million bed days emergency admissions for people in last year of life

6 The Role of The Acute Medical Unit in Advanced Care Planning Communication 100 consecutive patients with: Heart Failure Chronic Obstructive Airways Disease Dementia Cancer 45% identified as high risk of death within 6-12 months Gold Standards Framework 3% had ACP in place 0% was ACP available to AMU staff 15% prompt as to ACP on discharge

7 The Role of The Acute Medical Unit in Advanced Care Planning Communication Build links with primary care to ensure ACP information available on admission Electronic Paper Verbal Be robust in ensuring ACP discussions either initiated or prompts to initiate post discharge

8 The Role of The Acute Medical Unit in Advanced Care Planning Communication GSF Thinking Ahead Co-ordinate My Care

9 Dealing with Death Dying patients will come to us Dying patients will die with us We have a responsibility to them and their families How can we best discharge that responsibility

10 Friday am PTWR Side Ward 22 ATSP by nursing staff: Please prioritise. Mr X. 80s, Frail Admitted overnight. Sepsis. AKI. Modest response to initial treatment. Semi alert Family members present. Multiple Family members elsewhere in country Strong cultural / religious beliefs

11 Issues to consider: Clinical situation Emotional situation Side Ward 22 Patient Relatives Rest of day /tomorrow

12 Side Ward 22 Black and Grey Grey Grey Grey Grey

13 Side Ward 22 How to manage? As independent clinician Listen Assess Understand Plan Communicate Initiate and Review Listen, assess, understand, plan, communicate and review

14 Side Ward 22 Is the AMU the right environment? Multiple hand offs High flow Multiple distractions Should we transfer elsewhere? We know patient and relatives Death anticipated soon how soon? Refer to Palliative Care? May well provide additional support / guidance Continue to manage within Acute Medical Team? Often necessarily so.

15 Ingredients to getting it right Communication Communication Communication Written communication key Ensure future colleagues aware of details of plan etc Verbal communication key Convey the grey to immediate and future team members Documentation Hand-offs / Transfer of Care As for critically ill

16 Progress Side Ward 22 Deterioration throughout day Close liaison with family members including travelling relatives Close liaison with members of MDT Review of best interests: LCP Extensive written documentation Verbal liaison with colleague covering WE Introduction of colleague to patient and family anticipating requirement for Death Certificate out of hours etc

17 Side Ward 22 Outcome Died on the Saturday A good death for Mr X on the AMU Enduring benefit to family at time of loss MDT staff satisfaction given minimisation of uncertainty

18 Side Ward 13

19 Personal conclusion AMUs have pivotal role in ACP Dying patients and their relatives will come to us We have a responsibility to them and can have an enduring positive impact by: Owning the management / minimising patient moves Maximising communication between MDT and colleagues Verbal handoffs as well written communication Ensuring we lighten the grey

20 Thank You